Background

The COVID-19 pandemic has resulted in a global health emergency and lock-down measures to curb the uncontrolled transmission chain. Vaccination is an effective measure against COVID-19 infections. In Malaysia amidst the national immunisation programme (NIP) which started in February 2021, there were rising concerns regarding the prevalence of vaccine hesitancy and refusal, and therefore, vaccine uptake among Malaysians. Although there are many quantitative studies on COVID-19 vaccination, the subjective experience of individuals was understudied. This study aims to explore the lived experiences of Malaysians regarding vaccine hesitancy and refusal, and facilitating factors that could enhance vaccine acceptance and uptake.

Methods

This qualitative study employed the hermeneutic phenomenological study design. Purposive sampling strategies were used to recruit Malaysians that had direct experiences with friends, family members and their community who were hesitating or refusing to accept the COVID-19 vaccines. A semi-structured interview guide was developed based on the expert knowledge of the investigators and existing literature on the topic. A series of focus group interviews (FGIs) was conducted online facilitated by a multidisciplinary team of experts. The group interviews were transcribed verbatim and analysed.

Results

Fifty-nine participants took part in seven FGIs. We found that “incongruence” was the overall thematic meaning that connected all the 3 main themes. These themes comprise firstly, the incongruence between the aims and implementation of the National Immunization Program which highlighted the gap between realities and needs on the ground. Secondly, the incongruence between Trust and Mistrust revealed a trust deficit in the government, COVID-19 news, and younger people’s preference to follow the examples of local vaccination “heroes”. Thirdly, the incongruence in communication showed the populace’s mixed views regarding official media and local social media.

Conclusions

This study provided rich details on the complex picture of the COVID-19 immunization program in Malaysia and its impact on vaccine hesitancy and refusal. The inter-related and incongruent factors explained the operational difficulty and complexity of the NIP and the design of an effective health communication campaign. Identified gaps such as logistical implementation and communication strategies should be noted by policymakers in implementing mitigation plans.

1. World Health Organization. (2021). WHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int/
2. Adil, M. T., Rahman, R., Whitelaw, D., Jain, V., Al-Taan, O., & Rashid, F. (2021). SARS-CoV-2 and the pandemic of COVID-19. Postgraduate Medical Journal, 97(1144), 110–116. https://doi.org/10.1136/postgradmedj-2020-138386
3. Kupferschmidt, K., & Cohen, J. (2020). Race to find COVID-19 treatments accelerates. Science, 367(6485), 1412–1413. https://doi.org/10.1126/science.367.6485.1412
4. World Health Organization. (2020). Coronavirus disease (COVID-19): Herd immunity, lockdowns and COVID-19. https://www.who.int/news-room/q-a-detail/herd-immunity-lockdowns-and-covid-19
5. World Health Organization. (2021). Status of COVID-19 Vaccines within WHO EUL/PQ evaluation process. https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_15July2021.pdf
6. The Special Committee For Ensuring Access To COVID-19 Vaccine Supply (JKJAV). (2021). National COVID-19 Immunisation Programme. https://www.vaksincovid.gov.my/pdf/National_COVID-19_Immunisation_Programme.pdf
7. Aschwanden, C. (2021). Five reasons why COVID herd immunity is probably impossible. Nature, 591(7851), 520–522. https://doi.org/10.1038/d41586-021-00728-2
8. Jacobson, S. H. (2021, December 19). Why COVID-19 herd immunity now looks unattainable. Cleveland.com. https://www.cleveland.com/opinion/2021/12/why-covid-19-herd-immunity-now-looks-unattainable-sheldon-h-jacobson.html
9. Ministry of Health Malaysia. (2021). COVIDNOW in Malaysia. https://covidnow.moh.gov.my/
10. World Health Organization. (2014). Report of the SAGE Working Group on Vaccine Hesitancy. https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf
11. June, L. F. W., & Lee, C. T. H. W.Y. (2020). Factors influencing acceptance of COVID-19 vaccination among Malaysian adults.
12. Kementerian Kesihatan Malaysia [@KKMPutrajaya]. (2020, December 31). Hasil tinjauan vaksin #COVID19: Terima atau tolak? [Tweet]. Twitter. https://twitter.com/KKMPutrajaya/status/1344580831206023169
13. Syed Alwi, S. A. R., Rafidah, E., Zurraini, A., Juslina, O., Brohi, I. B., & Lukas, S. (2021). A survey on COVID-19 vaccine acceptance and concern among Malaysians. BMC Public Health, 21(1), Article 1129. https://doi.org/10.1186/s12889-021-11071-6
14. Larson, H. J., Jarrett, C., Eckersberger, E., Smith, D. M. D., & Paterson, P. (2014). Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine, 32(19), 2150–2159. https://doi.org/10.1016/j.vaccine.2014.01.081
15. Godin, G., & Kok, G. (1996). The Theory of Planned Behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, 11(2), 87–98. https://doi.org/10.4278/0890-1171-11.2.87
16. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15(2), 175–183. https://doi.org/10.1177/109019818801500203
17. Betsch, C., Schmid, P., Heinemeier, D., Korn, L., Holtmann, C., & Böhm, R. (2018). Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination. PLOS One, 13(12), Article e0208601. https://doi.org/10.1371/journal.pone.0208601
18. Tversky, A., & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185(4157), 1124–1131. https://doi.org/10.1126/science.185.4157.1124
19. Luz, P. M., Johnson, R. E., & Brown, H. E. (2017). Workplace availability, risk group and perceived barriers predictive of 2016–17 influenza vaccine uptake in the United States: A cross-sectional study. Vaccine, 35(43), 5890–5896. https://doi.org/10.1016/j.vaccine.2017.08.078
20. Bedford, H., Attwell, K., Danchin, M., Marshall, H., Corben, P., & Leask, J. (2018). Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology. Vaccine, 36(44), 6556–6558. https://doi.org/10.1016/j.vaccine.2018.08.055
21. Ward, P. R. (2017). Improving access to, use of, and outcomes from public health programs: The importance of building and maintaining trust with patients/clients. Frontiers in Public Health, 5, Article 22. https://doi.org/10.3389/fpubh.2017.00022
22. Fadda, M., Galimberti, E., Romanò, L., Faccini, M., Senatore, S., Zanetti, A., & Schulz, P. J. (2017). Validation of a scale to measure parental psychological empowerment in the vaccination decision. Journal of Public Health Research, 6(2), Article 955. https://doi.org/10.4081/jphr.2017.955
23. Machingaidze, S., & Wiysonge, C. S. (2021). Understanding COVID-19 vaccine hesitancy. Nature Medicine, 27(8), 1338–1339. https://doi.org/10.1038/s41591-021-01459-7
24. Centers for Disease Control and Prevention. (2021). Allergic reactions including anaphylaxis after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine — United States, December 14–23, 2020. MMWR. Morbidity and Mortality Weekly Report, 70(2), 46–51. https://doi.org/10.15585/mmwr.mm7002e1
25. Welsh, K. J., Baumblatt, J., Chege, W., Goud, R., & Nair, N. (2021). Thrombocytopenia including immune thrombocytopenia after receipt of mRNA COVID-19 vaccines reported to the Vaccine Adverse Event Reporting System (VAERS). Vaccine, 39(25), 3329–3332. https://doi.org/10.1016/j.vaccine.2021.04.054
26. Zakaria, Z., Sapiai, N. A., & Ghani, A. R. I. (2021). Cerebral venous sinus thrombosis 2 weeks after the first dose of mRNA SARS-CoV-2 vaccine. Acta Neurochirurgica, 163(8), 2359–2362. https://doi.org/10.1007/s00701-021-04879-x
27. Wyller, T. B., Kittang, B. R., Ranhoff, A. H., Harg, P., & Myrstad, M. (2021). Nursing home deaths after COVID-19 vaccination. Tidsskrift for Den Norske Legeforening, 141(10), 1–8. https://doi.org/10.4045/tidsskr.21.0383
28. ChannelNewsAsia. (2021, July 23). “Quite impossible” for COVID-19 vaccine recipient to be injected with empty syringe: Selangor health department. https://www.channelnewsasia.com/asia/malaysia-covid-19-vaccine-empty-syringe-broken-needle-1981781
29. DiGiovanni, C., Conley, J., Chiu, D., & Factors, Z. J. (2004). Factors influencing compliance with quarantine in Toronto during the SARS outbreak. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 2(1), 22–30. https://doi.org/10.1089/153871304322964719
30. van der Weerd, W., Timmermans, D. R., Beaujean, D. J., Oudhoff, J., & van Steenbergen, JE. (2011). Monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza A (H1N1) pandemic in the Netherlands. BMC Public Health, 11, Article 575. https://doi.org/10.1186/1471-2458-11-575
31. González-Melado, F. J., & di Pietro, M. L. (2021). La vacuna frente a la COVID-19 y la confianza institucional [The COVID-19 vaccine and institutional trust]. Enfermedades Infecciosas y Microbiología Clínica, 39(10), 510–515. https://doi.org/10.1016/j.eimc.2020.08.001
32. Rowe, R., & Calnan, M. (2006). Trust relations in health care—the new agenda. European Journal of Public Health, 16(1), 4–6. https://doi.org/10.1093/eurpub/ckj004
33. Marco-Franco, J. E., Pita-Barros, P., Vivas-Orts, D., González-de-Julián, S., & Vivas-Consuelo, D. (2021). COVID-19, fake news, and vaccines: Should regulation be implemented? International Journal of Environmental Research and Public Health, 18(2), Article 744. https://doi.org/10.3390/ijerph18020744
34. McEvoy, J. (2021, June 3). Microchips, magnets and shedding: Here are 5 (debunked) COVID vaccine conspiracy theories spreading online. Forbes. https://www.forbes.com/sites/jemimamcevoy/2021/06/03/microchips-and-shedding-here-are-5-debunked-covid-vaccine-conspiracy-theories-spreading-online/
35. Lim, S. (2021, August 7). Covid-19: Fake news, rumours, making people skip vaccine appointments, says Ongkili. The Star. https://www.thestar.com.my/news/nation/2021/08/07/covid-19-fake-news-rumours-making-people-skip-vaccine-appointments-says-ongkili
36. Islam, M. S., Kamal, A. H. M., Kabir, A., Southern, D. L., Khan, S. H., Hasan, S. M. M., Sarkar, T., Ali, S., Shogrove, S. F., Chughtai, A. A., & Seale, H. (2021). COVID-19 vaccine rumors and conspiracy theories: The need for cognitive inoculation against misinformation to improve vaccine adherence. PLoS One, 16(5), Article e0251605. https://doi.org/10.1371/journal.pone.0251605
37. Dubowitz, T., Nelson, C., Weilant, S., Sloan, J., Bogart, A., Miller, C., & Culture of Health Action Group. (2020). Factors related to health civic engagement: Results from the National Survey of Health Attitudes to understand progress towards a Culture of Health. BMC Public Health, 20, Article 20. https://doi.org/10.1186/s12889-019-7940-0
38. Luo, M., Ding, D., Bauman, A., Negin, J., & Phongsavan, P. (2020). Social engagement pattern, health behaviors and subjective well-being of older adults: An international perspective using WHO-SAGE survey data. BMC Public Health, 20(1), Article 99. https://doi.org/10.1186/s12889-020-08226-6
39. Agarwal, R., Dugas, M., Ramaprasad, J., Luo, J., Li, G., & Gao, G. (2021). Socioeconomic privilege and political ideology are associated with racial disparity in COVID-19 vaccination. Proceedings of the National Academy of Sciences, 118(33), Article e2107873118. https://doi.org/10.1073/pnas.2107873118
40. Wagner, C. E., Prentice, J. A., Saad-Roy, C. M., Yang, L., Grenfell, B. T., Levin, S. A., & Laxminarayan, R. (2020). Economic and behavioral influencers of vaccination and antimicrobial use. Frontiers in Public Health, 8, Article 614113. https://doi.org/10.3389/fpubh.2020.614113
41. Thomson, A., Robinson, K., & Vallée-Tourangeau, G. (2016). The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine, 34(8), 1018–1024. https://doi.org/10.1016/j.vaccine.2015.11.065
42. Roberts, R. J., McGowan, A., & Cottrell, S. (2016). Measuring inequalities in immunization in Wales and the impact of interventions. Human Vaccines & Immunotherapeutics, 12(10), 2704–2706. https://doi.org/10.1080/21645515.2016.1191717
43. Brown, K., Fraser, G., Ramsay, M., Shanley, R., Cowley, N., van Wijgerden, J., & Green, J. (2011). Attitudinal and demographic predictors of Measles-Mumps-Rubella Vaccine (MMR) uptake during the UK catch-up campaign 2008–09: Cross-sectional survey. PLoS One, 6(5), Article e19381. https://doi.org/10.1371/journal.pone.0019381
44. Heidegger, M. (1962). Being and Time (7th ed.; J. Macquarrie & E. Robinson, Trans.). Harper. (Original work published 1927).
45. Neubauer, B. E., Witkop, C. T., & Varpio, L. (2019). How phenomenology can help us learn from the experiences of others. Perspectives on Medical Education, 8(2), 90–97. https://doi.org/10.1007/s40037-019-0504-2
46. Clancy, M. (2013). Is reflexivity the key to minimising problems of interpretation in phenomenological research? Nurse Researcher, 20(6), 12–16. https://doi.org/10.7748/nr2013.07.20.6.12.e1201
47. Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2009). The phenomenological focus group: An oxymoron? Journal of Advanced Nursing, 65(3), 663–671. https://doi.org/10.1111/j.1365-2648.2008.04922.x
48. Gadamer, H. G. (2014). Truth and Method. Bloomsbury Academic.
49. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Sage Publications.
50. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042
51. Government of Malaysia. (2021). MySejahtera. https://mysejahtera.malaysia.gov.my/intro_en/
52. Safeek, A. R. (2021, August 11). Clips of packed queues at PPV goes viral. New Straits Times. https://www.nst.com.my/news/nation/2021/08/717133/clips-packed-queues-ppv-goes-viral
53. Lee, H. G. (2021, June 28). Is Malaysia in trust deficit in managing Covid-19? The Star. https://www.thestar.com.my/business/business-news/2021/06/28/is-malaysia-in-trust-deficit-in-managing-covid-19
54. Yoursay. (2021, June 17). When politicians are far removed from suffering of the people. Malaysiakini. https://www.malaysiakini.com/news/581215
55. Muller, J. (2021). Active social media users as percentage of the total population in Malaysia from 2016 to 2021. Statista. https://www.statista.com/statistics/883712/malaysia-social-media-penetration/
56. Wui, K. L. T., & Wei, W. W. (2020). Framing Jawi-Khat move: A comparative analysis of Chinese, English and Malay-language newspapers in Malaysia. Jurnal Komunikasi: Malaysian Journal of Communication, 36(1), 194–210. https://doi.org/10.17576/JKMJC-2020-3601-11
57. Wong, L. P., Wong, P. F., & AbuBakar, S. (2020). Vaccine hesitancy and the resurgence of vaccine preventable diseases: The way forward for Malaysia, a Southeast Asian country. Human Vaccines & Immunotherapeutics, 16(7), 1511–1520. https://doi.org/10.1080/21645515.2019.1706935
58. Ogilvie, G. S., Gordon, S., Smith, L. W., Albert, A., Racey, C. S., Booth, A., ... & Sauvageau, C. (2021). Intention to receive a COVID-19 vaccine: Results from a population-based survey in Canada. BMC Public Health, 21(1), Article 1017. https://doi.org/10.1186/s12889-021-10982-8
59. Dabla-Norris, E., Sollaci, A., Lima, F., & Khan, H. (2021). Who doesn’t want to be vaccinated? Determinants of vaccine hesitancy during COVID-19 (IMF Working Paper No. 2021/130). International Monetary Fund.
60. MacDonald, N. E., & SAGE Working Group on Vaccine Hesitancy. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33(34), 4161–4164. https://doi.org/10.1016/j.vaccine.2015.04.036
61. Palamenghi, L., Barello, S., Boccia, S., & Graffigna, G. (2020). Mistrust in biomedical research and vaccine hesitancy: The forefront challenge in the battle against COVID-19 in Italy. European Journal of Epidemiology, 35(8), 785–788. https://doi.org/10.1007/s10654-020-00675-8